CurrentColorado Rocky Mountain Health PlansPolicy CS020.S

Cognitive Rehabilitation and Coma Stimulation – Community Plan Medical Policy

Defines outpatient coverage position for Cognitive Rehabilitation (CR) and the policy position that Coma Stimulation for Disorders of Consciousness is unproven and not medically necessary. Applies to UnitedHealthcare Community Plan except for specified state-specific versions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCognitive Rehabilitation and Coma Stimulation – Community Plan Medical Policy

Policy CodePolicy CS020.S

Change TypeTitle & coverage rationale revised; DOC defined

Effective DateDec 1, 2025

Next Review Date

Key ActionProviders must follow InterQual LOC: Outpatient Rehabilitation & Chiropractic criteria to establish medical necessity for outpatient Cognitive Rehabilitation prior to coverage decisions.

SourceLink

POLICY UPDATE CHANGES

Title changed and coverage rationale wording for Coma Stimulation updated to specify 'Disorder of Consciousness (DOC)'.

Definition of 'Disorder of Consciousness (DOC)' added.

Application (state-specific applicability) updated: multiple states added/removed from applicability list.

Supporting information, clinical evidence, description of services, and references updated.

1Not covered: Coma Stimulation indications (DOC)

1Covered when InterQual criteria met (Outpatient CR)

3Key CPT/HCPCS codes listed

Coverage Summary

Overview: This policy (Policy Number CS020.S) addresses outpatient Cognitive Rehabilitation (CR) services and the policy position on Coma Stimulation. Coverage stance is mixed: outpatient CR is covered when medical necessity criteria are met per InterQual ® LOC: Outpatient Rehabilitation & Chiropractic, while Coma Stimulation for Disorders of Consciousness is considered unproven and not medically necessary. Status: CURRENT. Effective date: 2025-12-01. Last review: 2026-05-01.

Policy Header

Policy numberCS020.S

PayerColorado Rocky Mountain Health Plans

Policy titleCognitive Rehabilitation and Coma Stimulation

Effective dateDecember 1, 2025

Last reviewMay 1, 2026

StatusCURRENT

Medical-Necessity Criteria

Cognitive Rehabilitation (Outpatient) - Medical Necessity

Covered when ALL of the following are met:

Outpatient Cognitive Rehabilitation Medical Necessity

Service Setting: Service is outpatient Cognitive Rehabilitation (policy applies to outpatient services only)
Clinical Criteria: Medical necessity clinical coverage criteria are met per InterQual ® LOC: Outpatient Rehabilitation & Chiropractic

Coma Stimulation / Coma Arousal

Not medically necessary when ANY of the following apply:

Coma Stimulation / Coma Arousal Not Medically Necessary:

Coding

Relevant CPT (Cognitive Rehabilitation)CPT

97129	Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies; direct (one-on-one) patient contact; initial 15 minutes.
97130	Therapeutic interventions that focus on cognitive function and compensatory strategies; direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure).

HCPCS (Coma Stimulation)HCPCSNot Covered

S9056

Coma stimulation per diem.

Provider Actions

Prior Authorization

Use InterQual criteria for medical necessity determination

Providers must follow InterQual LOC: Outpatient Rehabilitation & Chiropractic criteria to establish medical necessity for outpatient Cognitive Rehabilitation prior to coverage decisions; InterQual is used to assist in administering benefits.

Affected codes: 97129, 97130
InterQual reference: InterQual ® LOC: Outpatient Rehabilitation & Chiropractic

Denial Risk

Coma Stimulation Not Covered

Claims for Coma Stimulation (e.g., HCPCS S9056) for any Disorder of Consciousness are not medically necessary and are subject to denial.

Background and Evidence

Background: Cognitive Rehabilitation (CR) is described as a multidisciplinary outpatient treatment program designed to improve cognitive functions (memory, attention, executive function, language, visuoperceptual skills) using restorative and compensatory approaches to maximize functional independence.

Coma Stimulation involves multimodal sensory stimulation intended to promote awakening or improve arousal in individuals with disorders of consciousness. The source states there are no established protocols or definitive patient selection criteria for these stimulation programs.

Evidence for coma stimulation is insufficientunproven and not medically necessary for any Disorder of Consciousness (DOC).

Evidence / Rationale

Definitions

Cognitive Rehabilitation (CR)A multidisciplinary treatment program designed to improve cognitive function and retrain abilities to think, use judgment, and make decisions using restorative and compensatory approaches; goal is to maximize functional independence.

Coma StimulationUse of multimodal sensory stimulation in an attempt to speed recovery from coma or improve arousal level.

Revision History

12/01/2025revised

Title changed and coverage rationale wording for Coma Stimulation updated to specify 'Disorder of Consciousness (DOC)'. Previously stated language referencing comatose, vegetative or minimally conscious state was replaced with wording referencing DOC.

12/01/2025added

Definition of 'Disorder of Consciousness (DOC)' added: 'A state of prolonged altered consciousness, which can be categorized into coma, vegetative state, or minimally conscious state based on neurobehavioral function.'

03/01/2026revised

Application updated: Added language indicating this Medical Policy does not apply to the state of Idaho and Pennsylvania; refer to state-specific policy versions.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyCognitive Rehabilitation and Coma Stimulation – Community Plan Medical Policy

Policy CodePolicy CS020.S

Change TypeTitle & coverage rationale revised; DOC defined

Effective DateDec 1, 2025

Next Review Date

Key ActionProviders must follow InterQual LOC: Outpatient Rehabilitation & Chiropractic criteria to establish medical necessity for outpatient Cognitive Rehabilitation prior to coverage decisions.

SourceLink

On This Page

Coma Stimulation (also known as coma arousal, coma responsiveness, multisensory stimulation, and coma care therapy/programs) is provided for any Disorder of Consciousness (DOC)

Policy states Coma Stimulation is unproven and not medically necessary due to insufficient evidence of efficacy for any Disorder of Consciousness (DOC)

Affected code: S9056

Claims are subject to denial as not medically necessary for any Disorder of Consciousness (DOC)

Documentation Required

Refer to federal/state/contractual benefit terms

When deciding coverage, reference applicable federal, state, or contractual requirements as they may supersede this policy; providers should document benefit applicability and state-specific policy references.

Document which federal, state, or contractual benefit terms apply to the member
Refer to state-specific policy versions where this Medical Policy does not apply

Disorder of Consciousness (DOC)A state of prolonged altered consciousness categorized into coma, vegetative state, or minimally conscious state based on neurobehavioral function.

Relevant CodesCPT 97129, 97130 (cognitive rehabilitation); HCPCS S9056 (coma stimulation per diem)

04/01/2026revised

Template update: Removed content/language pertaining to the state of Louisiana from the Application section.

05/01/2026revisedLatest

Application updated: Kentucky state-specific policy reference link updated to reflect the current title for state-specific policy version.

12/01/2025clarified

Supporting information, clinical evidence, description of services, and references updated; previous policy version archived.